Natural Embodiment through Wild Connections Registration Form
Please fill in all fields below
Personal Details
Name
*
First Name
Last Name
Preferred Name (nickname)
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State
Postcode
Date of birth
*
-
Day
-
Month
Year
Date
Health Information
(Strictly confidential)
Height (cm)
*
Weight (kg)
*
Have you ever had any of the following conditions:
Allergies
Asthma
Diabetes
Epilepsy / seizures
Haemophilia
Heart condition
High blood pressure
Hypoglycaemia
Phobias
Other
If you answered yes to any of the above please provide details:
Do you have any allergies to insect bites or stings that could result in anaphylactic shock?
*
Yes
No
If yes please provide details
Do you have any injuries or mobility issues?
*
Yes
No
If yes please provide details
Have you had a tetanus shot in the last 5 years?
*
Yes
No
Are you receiving treatment from a medical or health care practitioner for any significant physical or psychological reason, or is there anything we should know about your physical or psychological history?
*
Yes
No
If yes please provide details
If yes, has that medical practitioner agreed to you attending this program?
Yes
No
Have you had any mental health diagnosis in the past?
*
Yes
No
If yes please provide details
Dietary Needs
Do you have any of the following dietary issues
Gluten intolerance
Dairy intolerance
Nut allergy
Other
Are you
Vegetarian
Vegan
Other
Please provide more details as needed
Relationship with Nature
How would you describe your relationship with Nature?
*
How often do you get outdoors and what does that look like?
*
What made you say 'yes' when you heard about this program?
*
What are you hoping to get from the weekend?
*
Further info
Anything else you'd like us to know?
Submit
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